Healthcare Provider Details

I. General information

NPI: 1679110506
Provider Name (Legal Business Name): DAVID HERZKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12411 GAYTON RD
RICHMOND VA
23238-2272
US

IV. Provider business mailing address

516 SHADY OAKS TRL
BURLESON TX
76028-2320
US

V. Phone/Fax

Practice location:
  • Phone: 804-741-9494
  • Fax:
Mailing address:
  • Phone: 817-933-5432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JULIA KING
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 817-933-7582